Sports you plan to participate in at Wittenberg:
Preferred Language (if other than English)
Employed
Employer
Emergency Contact Information
Primary Care Physician
Primary Care Physician Phone
Primary Care Physician Fax
Primary Care Physician Address
Father/Guardian
Work Phone
Home Phone
Cell Phone
Father/Guardian Address
Mother/Guardian
Mother/Guardian Address
Alternate Contact
Home/Cell Phone
Primary Insurance
Insurance Address
Policy Number
Subscriber Name
Relationship
Secondary Insurance (if applicable)
Please read and initial each line.
1. I have enclosed a copy of my Primary and/or Secondary Insurance card/s front and back OR note that I have no insurance coverage.
2. I understand that my co-payment is due at each visit (if no insurance, a $45 office fee will be charged) I will bring a picture ID at each visit.
3. I understand that fees for services not covered by the agreement with Mercy Health/ Wittenberg will be billed to insurance and may have co-insurance due according to policy coverage. For those students without any coverage, fees associated with services not covered by the agreement with Mercy Health/Wittenberg will be billed to the students.
NOTICE: I attest that the above information is correct to the best of my knowledge. I authorize the release of any medical or other information necessary to process the claim. I also request payment of insurance benefits either to myself or to the party who accept assignment. I authorize payment of insurance benefits to the physician or supplier for all services rendered. I also understand and agree that regardless of my insurance status, I am ultimately responsible for the balance of my account for any professional services rendered or fees associated with my care. I also agree that I am responsible for any collection fees should my account be turned over to a collection agency.
Signature of Person Responsible (Student signature if 18 or older)
